Mental Health Issues of Students Who Cross Borders

Editor's note: This article was originally published in the Summer 2000 issue of International Educator. In celebration of NAFSA's 75th anniversary, IE is taking a look back at the topics and moments that have defined the field since the magazine began publication 33 years ago.

International students are examples of the human species’ ability to adapt to new situations and environments. The majority of these students accomplish this adaptation with remarkable effectiveness. Most also experience stress during the transition. International educators have an important role to fill as guides in insuring students in transition learn how to maintain their psychological wellbeing while they are on their sojourn. One of the most important lessons of the international sojourn may be gaining the self-knowledge that one can live and function quite effectively in a foreign culture. Once this vision is added to the student’s self-concept, it provides a new way of looking at oneself for the rest of the student’s life. By contrast, a psychological crisis that sends the student home prematurely may leave the student doubting his or her ability to function outside the home culture for a long time, even a lifetime.

This article examines the role of the international educator as it relates to facilitating counseling and mental health services for students who cross borders to pursue educational goals. The suggestions presented here are drawn primarily from the experience of the author in working with students from overseas who have come to study in the United States; however, many of the suggestions and the information provided can be of help for the study abroad educator as well.

For the international educator who is concerned about the mental health of students who cross borders, there is advice: prevention, prevention, and prevention!

Prevention: What to Do In Order To Lower the Risk of a Mental Health Crisis on Your Campus

Research indicates that a significant percentage of international students are not personally well adjusted—DeArmand (1983) reports that approximately 25 percent are not, while Thompson and Bentz (1975), as quoted in Zwingmann and Gunn (1983), report that only 33 percent have a personality score associated with "good mental health"—suggesting that the international educator should improve the campus atmosphere in order to provide support for students from overseas. This problem of mental health is most significant during the first semester and first year of the sojourn when the student is least knowledgeable about the host culture and still grieving the loss of contact with the home culture. A student at this stage of the sojourn has little knowledge of options and resources in the new environment and feels the loss of friends, family, and home more acutely than during a later stage of the sojourn.

One of the most important lessons of the international sojourn may be gaining the self-knowledge that one can live and function quite effectively in a foreign culture.

Clearly there are a number of factors that can increase or decrease the risk that a student will have serious cross-cultural adjustment difficulties. One of these factors is the degree of cultural similarity between the host country and the home country of the student. Canadian, British, Irish, and other students from English-speaking nations will probably have an easier time in the United States. Western Europeans also would have a relatively easy adjustment, with Latin Americans, and Middle Eastern students falling midway on the adjustment continuum. Asian and African students generally have the most difficult time, due to the larger cultural leap they must make in order to adjust. Students from these regions are also physically different, and this may make the transition more challenging, in spite of the American melting pot analogy that is so frequently cited.

Factors that make the adjustment difficult include: financial strain; bias against the student's homeland; differences in dress, climate, and religion; fear of losing one's culturality; shifts from rural to urban environments (and the reverse); and whether there is a common ethnic community to which the student relates on campus or nearby.

Often international students feel like outsiders on U.S. campuses and that they must tow the line with their compatriots by not mingling with members of ethnic groups that would be considered enemies back home. Failure to play along may lead to becoming an outsider with not only their hosts, but also their compatriots. The international educator also needs to be sensitive to the few students from one national or ethnic group who feel ill-at-ease because they encounter many members of an antagonistic group on campus or in the neighboring community.

International students arrive in the United States with some general awareness that racism is an issue. At home, the same tensions may occur along class or religious lines. International students of color are part of the race issue in the United States, whether they want to be or not, and may find themselves the victims of racism.

Another dynamic that keeps international and U.S. students apart occurs when American students are viewed as superficial and hard to get to know because American students rarely take the time to invest in a close, ongoing relationship. As with all stereotypes, there is at least a grain of truth: Americans, with their highly mobile lifestyle, are used to the coming and going of friends as they are uprooted for reasons of employment or education. Students from overseas are sometimes viewed by U.S. students as bookish, and having difficulty with English conversation. There is a double barrier of mutual stereotyping.

Alexander, Klein, Workneh, and Miller (1981) stress that there is a relationship between the level of traditional values held by the international student and the level of intimate involvement with U.S. students. The more traditional the outlook of the international student, the more likely the student will interact with compatriots and the more likely the student will have few or no interactions with U.S. students. Less traditionally minded students tend to move more freely across the cultural barrier on U.S. campuses. Self-confidence seems to be another key ingredient in crossing this barrier. It also is related to better English language skills, a better sense of wellbeing, less loneliness, and more academic achievement. In essence, these authors imply that a cultural and personal defensiveness may lead to congregating with compatriots rather than with host country students. By contrast, willingness to seek out new experiences and try new things may be a key ingredient for succeeding on an Ameri­can campus.

International students of color are part of the race issue in the United States, whether they want to be or not, and may find themselves the victims of racism.

It is good preventative mental health care for the international educator to be sensitive to these factors so that there is a sense of how much risk each international student carries. To achieve this, international educators should ask recently arrived international students about the events that led up to their coming to the United States. In general, this can help international educators understand the amount of pressure the international student is under to succeed in the United States. It is advantageous for international educators to be aware of this "emotional baggage" that students carry and how this may be manifested. Headaches, stomach aches, tiredness, and changes in eating and sleeping patterns are possibly signs of stress related to pressures carried from the homeland and culture shock.

Suggestions for Mental Health Baseline Assessment

• How well does the international student speak English?
• How interested is the student in meeting other compatriots ... or not meeting them?
• How interested is the student in meeting Americans or international students from homelands different from their own for sightseeing, socializing, and other group activities?
• Is the student studying in the United States because of selection as an outstanding student?
• Is it financial privilege that allows the student's study in the United States?

Using a tool, such as a "stress index," can facilitate the ability of international educators to gain a general sense of the level of stress that a student may be facing.

New Student Orientation

New students are often at higher risk of having mental health problems, and the international educator should spend time with these students in prevention activities. Orientation programs should, of course, include information on cross-cultural adjustment. Students should be made aware that it is normal that having homesickness and serious doubts about the decision to study abroad will surface during the first year of the sojourn. Once orientation has been completed, the international educator may check in with high-risk students on a regular basis. It may develop naturally that they can be encouraged to stop by to see personnel in the office on a regular basis.

The typical student from overseas is not here to learn about Americans and their culture. One exception may be to learn English, but frequently this is seen as an important tool to succeed—a means to an academic end. Even if students do socialize, they may feel guilty about what is frequently seen as a "waste of time" given the considerable academic demands they face and the fact that reading and writing in English may take them longer than their American counterparts.

Students should be made aware that it is normal that having homesickness and serious doubts about the decision to study abroad will surface during the first year of the sojourn.

Some education may be needed to train international students to use their contacts with Americans in recreational activities as a means of moving away from their work temporarily so that they can return to their studies more energized and effective. It may take constant reiteration of the theme, "Don't work hard, work smart," before the student is able to accept this counterintuitive advice. Gary Althen, in an article in the NAFSA Newsletter some years ago, wrote on the subject of teaching foreign students how to socialize at parties. This article is worth sharing with international students at orientation and at different times during the year when they would benefit from moving away from their academic work to gain perspective and to recharge.

Adjustment Issues

As the semester unfolds, it will become clear who is making an effective adjustment and which students are not. This may be the time to press for regularly scheduled sessions with a counselor. These struggling students should be given the option of inviting a friend or fellow student to counseling sessions. Consider two to three sessions weekly that are brief. A key goal for these sessions is to assist the student in replacing the losses that resulted from this transition.

Cognitive behavioral approaches may be ideal for the student because they are easy to understand, address the behaviors that are problematic, and improvement is possible after a few sessions. In this method, the therapist and the student enter into an alliance in which they decide the behavior and thoughts the student wants to change. A schedule of activities and a plan is developed for the student to work on. Often the therapist may provide brief readings or may be available by phone if the student is having a particularly difficult time. These techniques are particularly helpful for the depressed student because he or she leaves the session with a way to move out of the difficult situation with the support of another person.

One ongoing task that needs constant work is the development of a community contact list of ministers, mental health professionals (including psychiatrists, psychologists, psychiatric nurses, and social workers), community events, services, restaurants, etc. that cater to the needs of the students from overseas. It is important to know which faculty members have served in the Peace Corps and where they have served, and if anyone else on the campus and community has lived and studied overseas, and where.

Psychological Trouble

Alexander, Klein, Wokneh, and Miller (1981) state that when a student is in psychological trouble they experience themselves as deviant in both the host and home culture. Students feel out of control and this leads to unhappiness, anxiety, concerns about their American hosts, and a self-conscious perception that all their mistakes, linguistic and behavioral, are obvious and the butt of jokes.

These authors talk about depression caused by loss of social anchorage, status, or any familiar routine in which events can be easily predicted, and breaks in the ties with loved ones, friends, and family. It is also noted that it is rare that sojourners cross borders without losing most or nearly all of the sources of self-esteem. All of this sets the stage for the experience of homesickness, an area that psychologists have only recently begun to seriously investigate (Van Tilburg 1997).

The international student is faced with the loss of peers and family members. Where there is less external stimulation from friends, there is an increase in internally-generated stimulation, sometimes in the form of self­consciousness or paranoia about how the host country students view the stranger. This heightened sense of one's own feelings may explain why somatic complaints may occur. The distressed student is not distracted enough to overlook the emotional and physical discomfort being felt.

The international student may maintain a guarded and passive role that makes the U.S. therapist feel ineffective or that the cross-cultural gap is too great to bridge. When matters become serious and the international student is seriously distressed, it is important that the therapist take a directive role that is supportive. Keep in mind that one of the major stresses for international students is the unpredictability of life in the new setting. One can gain confidence with a frightened international student by explaining what will come next, such as what the mental health practitioner will ask, what a mental status examination is and how it is conducted, the possibility that medications will be prescribed and how they can help the student, and what the side effects are of the medication. If the helping professional can serve as a guide, the international student who is experiencing difficulty may be willing to engage and use the services provided. The student may need a list of ways that the problem would be resolved in the host culture. The international educator might respond, "Ah yes, we have a counselor (lawyer, gynecologist, mullah) who works with our students who have this problem all the time." Such an intervention "normalizes" problems and offers reassurance that resources are available to resolve the difficulty.

Keep in mind that one of the major stresses for international students is the unpredictability of life in the new setting.

Clearly the strategy is to make oneself available early in the process in order to gain the confidence of the student and to dispel the belief that the counselor or psychologist will have the student committed or sent home. This may involve identifying agencies or individuals who can provide help and are recognized by the student as helpful. Of course, if this is done early in the relationship, when a major crisis occurs, the international educator has the credibility he or she needs to be accepted as a helper and the authority to make decisions with, or for, the student who may not be able to do so. The groundwork of developing trust has already been laid and both student and international educator can focus on the problem at hand.

Providing Support During a Mental Health Crisis

If the international educator has done the preventative work that is suggested in this article, the difficult process of managing a mental health emergency will be easier. This is especially true if the international educator is arriving on the scene and the international student who is having difficulty knows that person. For international students, the cause of the crisis is very likely related to the unfamiliar environment in which the student finds him or herself. In this sense, it is generally a relief and a comfort when an international educator arrives on the scene and the face is a familiar one.

When an international educator encounters a distressed student, it is probably easier if the student and educator retreat to a quiet office, such as the International Education Office, where the student can be shielded from curious eyes. If a close friend is available, that person's presence could be helpful and welcomed by the student. Ideally, international educators should position themselves so that the distressed student is near the door with the educator positioned in the room facing the door. This way the international educator can have an assistant outside the door ready to respond if help is needed and to serve as a gatekeeper to the room. It is particularly important that this person not let emergency medical technicians (EMTs) or other personnel arrive in the room unannounced. By facing the door, the international educator will be able to see when emergency personnel have arrived, and the distressed student can be quietly informed of their arrival. It is a good idea for the international educators to tell the students that they are going to go out to talk with the assisting personnel and plan to return with them.

It is especially important that the distressed student not feel tricked or ambushed. It is also possible that the student simply needs a "time-out" and a chance to talk about whatever the precipitating event was that caused the difficulty. In this situation, it may be possible to provide the necessary counseling on the spot or to call for the assistance of the counseling center. If the crisis does pass, and it is assessed that the student is able to leave, a backup plan is needed. The plan should consist of a hotline number; a clear and precise "check in" time for the student to contact an appropriate helping professional; and the name of a key contact person, perhaps a close student friend who can be reached if there is more difficulty. Frequently it is a good idea to make it clear that it is the student's responsibility to stop in or call to let a specific person know that the situation is manageable. This puts the student in control and builds an alliance that shows that he or she is managing the problem with the helping professionals. However, it should be made clear that if the distressed student does not check in, it will be assumed that all is not well and campus personnel will contact him or her. If the crisis is not manageable in this manner, additional support will be needed.

One of the more difficult decisions regarding a call for additional help is determining what constitutes an emergency. Clearly an international educator may be the professional who knows the student best, but there may be limitations to the educator's skills in assessing the level of urgency for the student receiving psychological services. EMTs and police personnel have clearer guidelines as to what situations require further assessment at a psychiatric facility or emergency room. A call for further assistance would certainly be made in the event that the student is destroying property or threatening to harm anyone, including him or herself.

It is especially important that the distressed student not feel tricked or ambushed.

The advantage that the international educator brings to the situation is a clear understanding of the organization of the institution and what is likely to transpire as the crisis unfolds. Very likely what may be most frightening to an international student is the inability to anticipate what will occur. There is the fear of the unknown and the concern that public shame will result from having sought out help, particularly as more help is called in to manage the crisis. Reassurance about the student not being left in the hands of strangers can be very comforting at this point.

Depending on the emotional state of the student, he or she needs to know that the helping professionals will ask a series of questions to assess the student's grasp of reality and if the student is excitable, depressed, or aggressive. Throughout this experience, the international educator will need to determine whether information about this procedure will be upsetting or calming. Manic, excitable, angry, or aggressive behavior may escalate upon the student hearing about this procedure. Depressed students may benefit from an explanation of what procedures are to follow. Frightened students may be comforted by the explanation, but each individual is different and it is not uncommon for the reaction to be one of panic.

The dynamics are very complex, but a key point is that there is a greater chance that an international educator will be seen as an adversary if the student is not informed fully about the arrival of additional personnel to assist. The less that is said to the student, the more likely that the international educator will not be perceived as part of the band of assistants who will be intruding, and possibly pressing to have the student go to the hospital. An international educator can make a unique contribution of being a "cultural informant" or guide for the student in emotional crisis. Evidence that the student is a threat will lead to a decision to have the student taken to an emergency room or psychiatric facility.

Some students may feel that they are out of control, and may be waiting for a therapist to put this, as well as other difficult statements, into words for them. The therapist always needs to be working from a developmental model: When will the patient be ready to take a given step? Can the student be given enough time to come to the obvious conclusion, be it hospitalization or return to the homeland?

International educators need to be aware that the uniforms of EMTs and security personnel may be a trigger for international students. Furthermore, depending on the protocol on the campus and in the community, once an ambulance is called, there may be a concurrent response from local police, sheriff, or state troopers. The arrival of armed and uniformed personnel may heighten the anxiety and distress of the student in crisis. It may be important for the international educator to serve as an intermediary for the group of "helpers" arriving on the scene. If the educator is known and respected by the EMTs and security personnel, the educator will have a better chance to influence how things will proceed. However, the personnel may not have as much time to stand by until the student tries to regain composure. Also, it should be kept in mind for them, as well as for international educators, that students in psychological distress need to be assessed for their ability to take care of themselves. The acid test of a decision to release or admit for additional observation and care will be based on the student's potential for hurting anyone. Also, will postponement of care now create a more difficult crisis later? Some basic questions need to be asked in this situation, such as: Can this student function effectively if he or she returns to the classroom and his or her regular routine? If not, is it prudent that he or she immediately receive additional care in order to prevent further decompensation and danger to self and others?

An international educator can make a unique contribution of being a "cultural informant" or guide for the student in emotional crisis.

As in situations where the police ask a student to cooperate, here too, refusal can lead to the student being forced to go to the hospital. The international educator needs to discuss this with the student so that he or she is aware that a hospital visit may be required. How he or she goes may be negotiable. Ability on the international educator's part in negotiating such an interaction between the student and the emergency personnel may be key in keeping the situation from escalating into an even more traumatic event.

If indeed the situation requires a trip to a mental health facility for further assessment, there are a number of things that the international educator should know to better inform the student about an inpatient setting. As discussed earlier, a distressed student will be interviewed to assess the type and seriousness of the problem. However, there are some dear cultural biases in this type of assessment. For instance, besides being asked for their name, date and where they are, the patient may be asked to identify what county and what hospi­tal he or she is in. Patients are asked to do simple math problems, and sometimes they are asked to interpret proverbs. A good clinician with cross-cultural sensitivity should interpret the results of this exam with consideration for the international student's situation. Here, too, there is an excellent role for the international educator to play as informant and advocate. It is important for the international educator to be able to speak with mental health professionals and inform them of the student's functioning prior to being depressed, and also the student's level of acculturation and English language proficiency.

Some students may feel that they are out of control, and may be waiting for a therapist to put this, as well as other difficult statements, into words for them.

Diagnosis is a key step in the treatment process of persons suffering from psychological difficulties. Generally, a psychiatrist or psychologist will provide a tentative diagnosis after completing an intake interview. Decisions about the diagnosis will be made based on the Mini Mental Status Examination and information that the examiner gathers about behavior and symptoms described by the patient, family members, and close friends. In arriving at a diagnosis, the psychiatrist or psychologist will almost always use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This reference volume, a compendium of psychological maladies, contains a glossary of culture-bound syndromes that could prove helpful for international educators as basic reading in understanding cross-cultural mental health issues. This ref­erence manual should be in university counseling centers or college libraries.

Referring to this manual is most helpful in understanding and learning more about the 16 major diagnostic classes. However, it becomes clear as one reads through the descriptions of such diagnoses as social phobia or agoraphobia that it is difficult to distinguish between culturally sanctioned behavior such as quiet, passive behavior that may be seen as psychopathological in the host culture. Also, it should be noted that the tendency to avoid going out and being in embarrassing situations, where someone asks them a question in public, may be a coping mechanism for students who struggle with English every waking moment of their sojourns.

Another issue that may arise is the prescribing of psychotropic medications for students in crisis. Responses to such help can be varied indeed, as is the case with American patients as well. Good therapy requires that medication be one of several supports, including psychotherapy, for the student in crisis The student's attitude toward the medication needs to be assessed so that additional information can be provided to the student.

Generally the psychotropics are divided into four broad groups: antipsychotics (neuroleptics), anxiolytics (antianxiety agents), antidepressants, and antimanic medications. One factor that makes medications complicated is that each medication has two names, a generic and brand or trade name. Often brand names are different around the world, so it might be helpful to know the universal generic name of the medication. The best way for an international educator to gather medication information from a student is to ask him or her to present the vials so that the information can be copied directly from the label.

Many of the psychotropic medications are slow acting, taking several weeks before the patient begins to fell the effect of the medication. Working with these medications requires patience and often changes are made if results are not seen after several months. Another important aspect of these medications is that they do not cure psychological problems; they simply manage them. It may be necessary to continue to take the medication for a long time to insure that the depression or other problem is kept under control. This must be balanced against the risk of long­term side effects such as sexual dysfunction, weight gain, or purposeless motor activity that cannot be reversed.

Admission to a psychiatric facility can be a frightening experience for anyone. It can be yet another insult to the individual, verifying their inability to function outside the hospital. For some patients, admission to the hospital may be a relief in that the distressed student may feel that he or she no longer has to feel on the defensive, trying to hide the difficulties they are experiencing. Admission can also be considered a postponement of the feared trip home that will bring even more shame and embarrassment. As difficult as the admission may be, there is still the hope that the student can return to the campus, rather than face the most difficult situation of being sent home.

All international educators should have fundamental training in the area of cross-cultural counseling, especially so that they can make educated decisions about international students who are in psychological distress.  •

Terence P. Hannigan holds a Ph.D. and works for Deer Oaks Mental Health Associates in Laredo, Texas.